Provider Demographics
NPI:1265505333
Name:WATSON, T. GREGG (RPH)
Entity type:Individual
Prefix:MR
First Name:T. GREGG
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:MR
Other - First Name:T.
Other - Middle Name:GREGG
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1717 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53083-2146
Mailing Address - Country:US
Mailing Address - Phone:920-459-8457
Mailing Address - Fax:
Practice Address - Street 1:3529 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1865
Practice Address - Country:US
Practice Address - Phone:920-459-2755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10035-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10035-040OtherPHARMACIST LICENSE